DISEASE. prevention and. any disease and. added risk with. need additional. protection. SYMPTOMSS Scaling or cracking and itching of the skin,

Transcription

1 Washtenaw County Public Health Department Communicable Disease Office: Website: publichealth.ewashtenaw.org COMMON COMMUNICABLE S Reference for Childcare and School Personnel Individuals with immune deficiencies due to certain diseases, chemotherapy, radiation, steroid drug therapy, Or hemolytic problems may have added risk with any disease and need additional prevention and protection. **Communicable Disease Fact Sheets may be downloadedd at publichealth.ewashtenaw.org** Athlete's Foot (Tinea pedis) S Scaling or cracking and itching of the skin, especially between toes; blisters containing thin watery fluid Unknown HOW SPREAD Contaminated floors and clothing (socks and shoes) CONTAGIOUS Communicable for as long as lesions or viable spores are present PREVENTION Good personal hygiene Dry well between toes Use dusting powder, cream, or ointment with fungicide Wear cotton socks that breathe Regular use of disinfectant on high risk surfaces Keep nails short and clean READMISSION Not usually excluded from school Severe cases should be excluded from swimming pools and showers Chickenpox (Varicella) Sudden onset of fever, general discomfort, headache, loss of appetite, and lesions that appear in crops with most on the torso; have fluid for filled blisters (vesicles) 3 to 4 days that become scabbed. There are usually successive crops of vesicles. Later, reactivation of the varicella virus that causes chickenpox can lead to shingles days Average: days Direct Contact, droplets, or airborne spread of respiratory tract secretions; indirectly through articles soiled by discharge from lesions or mucus membranes Communicable as long as 2 days before eruption through 5 days or until all of the lesions are driedd or scabbed (whichever is longer) Report casess to WCPH CD Two dosess of vaccine Vaccine given within 72 hours of exposure may prevent or lessen the symptoms People that do not have chickenpox immunity can develop chickenpox after exposure to shingles Immune globulin and acyclovir may reduce disease in exposed children. Not less than 6 days after the appearance of the first crop of lesions All lesions must be crusted over Page 1

2 Clostridium difficile (C. diff) Watery diarrhea, fever, abdominal pain; typically associated with recent antibiotic use or hospitalization. Unknown Fecal oral, by direct contact or contact with contaminated surfaces Unknown Good personal hygiene to prevent oral fecal spread after toileting and before preparing food Alcohol based sanitizers are not effective Careful cleaning of contaminated surfaces with bleach based disinfectant Take antibiotics only as prescribed by your healthcare provider When stools are formed and other symptoms have subsided Common Cold Nasal stuffiness, runny nose, sneezing, irritated throat. Usually lasts 2 7 days. Extremely variable depending on the organism, usually less than 72 hours Aerosol breathing in virus particles. Touching surfaces and objects contaminated with droplets containing the virus. Communicable for up to 5 days after onset, but variable No exclusion necessary Cold Sores (Herpes Simplex I) Fluid filled blisters commonly found on the lips, gums, cheeks, and eye lids. Appear in repeated episodes days Direct contact with the lesions or fluid from the blisters Up to 7 weeks after the first infection and whenever blisters are present Avoid contact with the lesions No exclusion necessary Page 2

3 Depends on causative organism Croup Barking cough, difficulty breathing Depends on the causative agentdirect contact, airborne or respiratory droplet Depends on causative organism usually viral After free of viral infection symptoms and child is no longer experiencing difficulty breathing Diarrhea Giardia Salmonella Shigella Campylobacter E. coli, Shiga Toxin Cryptosporidosis Yersinia Loose or watery stools (with or without blood), cramping, and occasionally nausea, vomiting and fever 6 hours to 10 days depending on the causative organism Fecal oral spread Eating or drinking contaminated food/liquids, drinking unpasteurized apple cider and raw milk, and petting or touching animals. As long as diarrhea is present Report cases to WCPH CD Good personal hygiene after toileting and before preparing food Careful cleaning of contaminated surfaces with disinfectant Careful refrigeration of food Thorough cooking of all food derived from animal products Use of pasteurized milk and chlorinated water. Animals, including reptiles are possible sources of infection: stress hand washing after handling all animals Depends on causative organism (consult local health department) Page 3

4 Fifth Disease (Parvovirus B19, Erythema Infectiosum) Rash begins as solid red area on the cheeks ( slapped appearance), lace like rash spreads to the upper arms, legs, trunk, hands and feet 4 21 days Contact with respiratory secretions. Probably 2 days before rash and 4 5 days later Pregnant teachers in particular should be advised to wash their hands frequently and avoid sharing eating utensils No exclusion necessary (due to mild nature of disease) Flu (Influenza A & B) Sudden onset of fever 101 F or above, chills, headache, muscle pains, runny nose, mild sore throat, and severe cough that may last after other symptoms subside. Children may also experience GI symptoms. 1 4 days Direct contact with droplets. Airborne under crowded conditions in closed spaces. Virus may persist for up to 8 hours on a surface and be transmitted by direct contact. Adults: 1 day before to 5 days after symptoms start. Children can transmit 10 days or more after symptoms start. Vaccine may prevent disease or reduce the severity of symptoms Medication per health care provider may be effective for influenza Do not use Aspirincontaining products due to increased risk of Reye's syndrome Relapse may occur if activities are resumed too soon Must be free of fever at least 24 hours School/daycare closure has not proven effective in controlling the illness, but may be indicated due to high absenteeism of staff and students. Page 4

5 Hand, Foot and Mouth disease (Coxsackievirus) Sudden onset of fever and development of tiny blisters inside mouth, throat and on the extremities 2 days 2 weeks (Average: 3 5 days) Direct contact with nose and throat discharge and feces; aerosol droplet spread Probably from 2 3 days before onset to several days after onset. Very contagious during acute illness; virus may persist for weeks in feces. Avoid contact with infected persons Don t share eating utensils Disinfect diaper changing areas after each diaper change Disinfect toys frequently When recovered from acute illness. Must be free of fever for at least 24 hours. Hepatitis A Usually abrupt onset of symptoms; abdominal pain, fever, fatigue, lack of appetite and nausea, followed in a few days with dark urine, yellowing of the skin and eyes (jaundice) and lightcolored stools. Symptoms are generally absent or much more mild in children than in adults days (Average: days) Fecal oral contact Outbreaks related to contaminated food and water. Spreads rapidly in daycare settings especially if nontoilet trained children attend days before symptoms appear. Communicability lasts 1 week after jaundice appears. Report cases to WCPH CD Good personal hygiene after toileting and before preparing food Avoid eating raw seafood Wash all vegetables and fruit before eating and cooking Safe disposal of feces Two dose vaccination series is recommended for children age 12 months and older, as well as other high risk groups. Exclude for 1 week after onset of jaundice Page 5

6 Hepatitis B Usually mild to asymptomatic in children. Onset is usually slow with vague abdominal discomfort, lack of appetite, nausea, vomiting, joint pain, and rash. Fevers are usually absent or mild. Yellowing of the skin and eyes (jaundice) may appear late in the illness with urine becoming dark and lightcolored feces. Severity ranges from very mild to the very rare fatal case days (Average: days) Direct contact with blood and body fluids; not spread by feces, urine or vomitus. Contaminated needles Contamination of open wounds with blood and bodily fluids (cuts, bites, especially on hands) During close personal/sexual contact Perinatal transmission from infected mother Infective 1 2 months before the onset of first symptoms, through the acute clinical course. Persistently contagious if the chronic carrier state develops Report acute cases to WCPH CD Universal precautions (use gloves when handling blood or body fluids cleaning wounds, vomitus, stool, and other body fluids) Follow up spills by thoroughly cleaning with a disinfectant: virus persists on surfaces up to one week Safe disposal of all needles and sharps in sharps containers Washing hands thoroughly with soap and water after contact with blood or body fluids Three dose vaccination series Use of latex condoms during sexual contact No sharing of pierced jewelry, razors or toothbrushes No exclusion necessary Page 6

7 Hepatitis C Onset is usually asymptomatic but may include poor appetite, vague abdominal discomfort, nausea, and vomiting. Jaundice is less common than with Hepatitis B. 2 weeks 6 months Average: 6 7 weeks Direct contact with blood and body fluids Contaminated needles Contamination of open wounds with blood/body fluids During close personal/sexual contact (rare) Perinatal transmission from infected mother (rare) 1 + weeks before symptom onset. Chronic carriers are contagious persistently. Report acute cases to WCPH CD Universal precautions (use gloves when handling blood or body fluids cleaning wounds, vomitus, stool, and other body fluids) Follow up spills by thoroughly cleaning with a disinfectant No vaccine available No exclusion necessary Impetigo A skin disease marked by isolated pus filled spots (lesions) which break releasing a straw colored fluid. Occurs primarily around the mouth, nostrils and eyes Depends on infectious agent: Staphylococcal: 4 10 days Streptococcal: 7 10 days Direct contact with drainage from the lesions. People can be asymptomatic carriers. Easily communicable as long as lesions continue to drain or a carrier state exists. Avoid contact with the lesions Excluded until medically treated for 24 hours. Cover infected parts as indicated. Page 7

8 Lice (Pediculosis) Scalp itching and appearance of lice or eggs (nits) in the hair near the scalp. Nits stick to hair shafts days from egg laying to nymph hatching. 4 week life cycle Direct contact with infested person or indirectly through contact with infested articles of clothing or personal articles (linen, combs, earphones). Spread of the infestation can occur as long as viable nits are present. Nits remain viable on clothing for one month. Head lice can survive for 2 days off the host. Treat with pediculocide follow directions exactly Importance of retreatment if necessary Avoid sharing hats, scarves, brushes, combs or other personal effects Evaluate the need for support services: mass shampooing, housekeeping, financial assistance See Michigan Head Lice Manual online: ments/final_michigan_he ad_lice_manual_103750_ 7.pdf Exclude students with live lice infestation. Readmit after treatment. Rubella Mild illness with a rash that begins on the face and spreads to the rest of the body within 24 hours. The rash disappears in order of first appearance and is usually gone by the end of the third day. Swelling of the lymph nodes behind the ear and at the base of the skull days Average: days Droplet spread; contact with secretions from nose/throat; airborne via sneeze and cough 1 week prior to rash and at least 7 days after onset of rash. Report cases to WCPH CD Age appropriate immunization and immunization of susceptible contacts Pregnant woman contact primary care physician for diagnosis and follow up after exposure Excluded for 7 days after rash onset. Page 8

9 Measles (Rubeola) Meningitis (Bacterial: Hib, Meningococcal, Pneumococcal) Fever, cough, runny nose, red, watery eyes, small red spots in mouth, appearance of rash at hairline spreading downward over body, may have diarrhea or ear infection. Complications include pneumonia, brain inflammation, convulsions, deafness, mental retardation, or death. Severe headache, stiff neck and back, nausea/vomiting, fever, chills, mental confusion, sensitivity to light, purplish rash. May progress to unresponsiveness, coma and death. Hospitalization is usually necessary, as well as treatment with IV antibiotics days Average: 8 12 days Varies with the specific bacteria causing the meningitis Droplet spread or direct contact with nasal or throat secretions; airborne via sneeze and cough. Direct contact with the nasal discharge or saliva of an infected person through kissing, drinking from a common container, or sharing eating utensils. Also through droplets when the infected person coughs or sneezes. Highly communicable, usually 4 days before to 4 days after the rash appears Up to hours after starting antibiotics Report cases to WCPH CD Age appropriate immunization and immunization of susceptible contacts Keep ill child separated from others Need for medical diagnosis and follow up Report cases to WCPH CD Antibiotics recommended for close contacts depending on the type of bacteria causing illness Vaccination series for young children against Hib meningitis and pneumococcal infections are recommended 1 2 dose vaccination series for meningococcal meningitis is recommended for year olds Upon recovery, but not earlier than 4 days after the appearance of the rash. Exclude all unimmunized students from school if a case occurs in the building. Upon recommendation of health care provider with permitted activity level indicated Page 9

10 Varies with specific causative agent Meningitis (Viral, Aseptic) Severe headache, stiff neck and back, vomiting, sudden fever, irritability, intolerance of light, and sometimes a rash. Varies with specific agent but includes: Fecal oral route Inhaling droplets from infected person's cough or sneeze Mosquitoes which carry West Nile Virus Complication of viral illnesses, i.e. chicken pox Varies with the specific causative agent Report cases to WCPH CD Avoid sharing eating and drinking utensils Immunization against measles, mumps, rubella, varicella and polio Use of insect repellant Upon recommendation of health care provider with permitted activity level indicated. Infectious Mononucleosis (Mono, Epstein Barr virus) Fever, sore throat, enlarged lymph nodes, enlarged spleen, and fatigue 4 6 weeks Person to person through contact with saliva Prolonged; up to a year or more after infection Do not share eating and drinking utensils Sterilize all eating utensils Disinfect all toys and eating surfaces to decrease exposure to saliva Follow recommendation of health care provider Page 10

11 Variable Methicillin Resistant Staph. Aureus (MRSA) May appear as a pimple, boil, or abscess. The area may also be red, swollen, and painful, as well as having pus or other drainage present. A fever may be present. Person to person through skin toskin contact or sharing personal items. Wound drainage can spread infection to other parts of the body or to others. MRSA can survive on some surfaces for prolonged periods of time. As long as pus or other drainage is present. In some people, a carrier state exists with no signs of infection. No sharing of personal items (razors, towels, washcloths, bar soap, or clothing) Send students for medical assessment when signs of infection appear Machine wash and dry laundry at the warmest temperature recommended by laundry labels Clean and disinfect high touch or soiled areas frequently with an EPAregistered disinfectant Clean shared sports equipment between uses, and use a barrier between skin and equipment as feasible Students with open draining wounds should not participate in contact sports or swimming until the health care provider clears them for participation. Students may attend school if the wound can be covered with a dry dressing and will contain any drainage. Page 11

12 12 25 days Average days Mumps (Infectious Parotitis) Onset is gradual. There may be chills, discomfort, headache, and pain below the ears, accompanied by fever, followed by swelling of one or both salivary glands. Swelling appears in front of and below the ear and follows the jaw line. Swelling usually lasts 5 7 days. Direct contact with saliva or mucus, airborne, and droplet spread. 7 days prior to salivary gland swelling to 5 days after. Report cases to WCPH CD Age appropriate immunization Immunization of all susceptible contact Need for medical diagnosis and follow up Disinfection of surfaces or materials that may have germs such as desks and toys Avoid sharing eating and drinking utensils Exclusion until 5 days after onset of salivary gland swelling Norovirus Sudden onset of nausea/vomiting, diarrhea, stomach cramps, low grade fever, chills, headache, muscle aches and fatigue hours Fecal oral spread Contact with an infected person Touching contaminated surfaces and touching your mouth Handling or eating contaminated food or drinks. During the acute phase and up to 2 3 days after symptoms have stopped. Stool may contain virus for 2 weeks after symptoms have stopped. Good personal hygiene after toileting and before food handling or eating Flush any vomit or stool in the toilet Use 1 teaspoon bleach per 1 gallon water solution to clean and disinfect contaminated surfaces and toys for at least 10 seconds 48 hours after symptoms have stopped Page 12

13 5 21 days Average: 7 10 days Pertussis (Whooping Cough) The initial signs are mild coughing and runny nose. 1 2 weeks later, bursts of severe coughing start, sometimes followed by a high pitched gasp of air (called a whoop because of the sound). Vomiting can occur after coughing attacks. Cough may last as long as 3 months. Aerosolized droplets and direct contact with discharges from the respiratory tract (mucus from coughing and sneezing) Highly communicable in the early stages when the person has cold like symptoms and for 2 weeks after the beginning of coughing Report cases to WCPH CD Age appropriate immunization DTaP vaccination of close contacts less than 7 years of age that have not been appropriately vaccinated Tdap for close contacts at least 7 years of age that have not been appropriately vaccinated Antibiotics for household and other close contacts regardless of immunization status is recommended Exclusion until completion of 5 days of antibiotics, or 3 weeks after onset of cough if left untreated Pinkeye (Bacterial, Viral, Allergic Conjunctivitis) Viral: Common in adults and older children. One or both eyes may be affected; discharge is watery or clear mucus with significant redness. Bacterial: Common in children under 5 years. Involves one or both eyes and produces a thick yellow or green discharge, some redness possible. Bacterial: hours Viral: 5 12 days Direct contact with discharge from the eyes, coughs or sneezes. From contaminated fingers, clothing and other articles, including shared eye make up applicators, and multiple dose eye medications. During the period of active infection and for 2 3 weeks depending on the agent Good personal hygiene after contact with eyes Avoid handling clothing and personal items of infected persons Disinfect surfaces and articles Exclude until eye drainage is clear Allergic: Usually seasonal; involves intense itching, watery discharge, minimal redness in both eyes. Page 13

14 Pinworm (Enterobiasis) A mild itching in the anal area, disturbed sleep, irritability, and local irritation due to scratching 1 2 months Fecal oral contact Directly or indirect contact with contaminated clothing or bedding from an infected individual As long as pinworms are present in the intestine and laying eggs. The eggs can survive up to 2 weeks on clothing, bedding, toilet seats or other objects. Good personal hygiene Keep nails short Discourage scratching bare anal area and nail biting Disinfect all bathrooms and bedding. No exclusion necessary Poison Ivy, Oak, Sumac (Allergic Dermatitis) Moist, fluid filled blisters that often drain. Blister pattern varies. Itching may be severe. 1 3 days Direct contact with toxic oil from leaves, pets, clothing Can be airborne in moisture or smoke from burning leaves Not contagious Avoid contact with poisonous trees and plants Wash all clothing after exposure Bathe animals Wash skin immediately with lukewarm water and soap No exclusion necessary Cover infected part as indicated Secretions from blisters will not spread poison to others Page 14

15 1 3 weeks Ringworm of the Body (Tinea Corporis) Lesions on the skin characterized as flat and ring shaped. The inside of the ring may either be moist with pus and crusty or dry and flaky. The center tends to heal as the circle widens. Direct or indirect contact with skin lesions of infected persons or animals Contaminated floors, shower stalls, benches, etc Communicable as long as lesions are present or fungus is on contaminated material Good personal hygiene Early detection and treatment May need to inspect siblings and contacts if outbreak is present Appropriate cleansing of shower rooms and gym equipment Exclusive personal use of towels and clothing After treatment is started Wrestlers should not return to sport until 72 hours after starting treatment Exclude cases from swimming pools until treatment is completed Ringworm of the Scalp (Tinea Capitis) Infection begins as small circular lesions which may be associated with an area of baldness. Infected hairs become brittle. Lesions are occasionally raised and pus filled. 1 3 weeks Direct/indirect contact with cushions, hair clippers, clothing, and toiletry articles contaminated with infected human/animal hair Animals, especially cats, may be carriers Communicable as long as lesions are present; fungus may remain on contaminated material for some time Early detection of cases Prompt treatment Awareness that pets may have spread the disease and need treatment Daily hair washing during treatment Avoid sharing hats, brushes, combs or other hair accessories After treatment is started Page 15

16 Roseola Sudden high fever ( F) which falls with the appearance of a rash on about the third or fourth day of the illness. Most cases are age 6 months 3 years. The rash consists of small rose pink spots which first appear on the chest and abdomen but may spread to the face, legs and arms. The rash is usually limited to 1 2 days days Airborne and direct contact with droplets from the nose, throat, and mouth by sneezing, coughing and speaking. Unknown May spread from a carrier with no symptoms Disinfection of surfaces or materials that may have germs such as desks and toys, especially those that may be placed in a child s mouth After rash clears Scabies Small pimples, blisters and tiny burrows that appear as slightly off color lines. Areas most affected are skin folds, such as in between the fingers, inside elbows, on inner thighs and genital area, and between the buttocks. Intense itching, especially at night when mites are active (may disturb sleep). Areas may become infected due to scratching. 4 6 weeks for the first exposure 1 4 days for re infestations Usually through direct contact with an infested person, and to a limited extent by contact with freshly contaminated linen or clothing Until mites are destroyed by chemical treatment. A second treatment, one week after the first course, is often needed. Report 2+ cases in one classroom to WCPH CD Early detection of cases Good personal hygiene Appropriate treatment including evaluation by health care provider following all recommendations closely Exclude suspect cases until evaluated/cleared medically Evaluate the need for support services assistance See Michigan Scabies Manual online: ocuments/scabies_manual_ _7.pdf Upon completion of health care provider prescribed treatment. Page 16

17 Scarlet Fever (Streptococcal Infection) Fever, sore throat, tonsillitis or pharyngitis, bright red tongue; fine, rough rash that appears on the neck, chest and skin folds. 2 5 days Direct contact with respiratory secretions or sores from the infected person. Rarely spread through indirect contact with surfaces or objects. Can be spread through contaminated food. From the time of infection up to 24 hours after starting antibiotic treatment. Remains communicable for days if left untreated Early detection of cases Proper use of antibiotics: complete prescription whether symptoms persist or not! Continued medical follow up if symptoms persist or new ones develop Disinfection of bathroom objects such as tooth brushes, cups, etc Do not to share utensils or oral care products Upon approval of a health care provider, but not less than 24 hours after starting antibiotic treatment. Strep Throat (Streptococcal Infection) Fever, severe sore throat, tonsillitis, pharyngitis, tender lymph nodes behind the ears. 2 5 days Direct contact with respiratory secretions or sores from the infected person. Rarely spread through indirect contact with surfaces or objects. Can be spread through contaminated food. From the time of infection up to 24 hours after starting antibiotic treatment. Remains communicable for days if left untreated Early detection of cases Proper use of antibiotics: complete prescription whether symptoms persist or not! Continued medical follow up if symptoms persist or new ones develop Disinfection of bathroom objects such as tooth brushes, cups, etc Do not to share utensils or oral care products Upon approval of a health care provider, but not less than 24 hours after starting antibiotic treatment. Page 17

18 Tuberculosis (TB) Most children have no symptoms when first infected. Disease may progress to pulmonary TB (the most common form of the disease). It starts with high fever, night sweats, and weight loss. Later symptoms include persistent cough, chest pain, hoarseness, and coughing up blood weeks Inhaling airborne particles from infected persons during coughing, sneezing, talking and singing. Variable. After starting treatment with anti TB drugs, person will be monitored for infectivity Report any suspect/active TB skin tests cases to WCPH CD Department immediately. Testing of at risk populations The importance of taking all anti TB meds as ordered to decrease the risk of further complications The importance of reducing overcrowding and maintaining good air circulation to reduce the risk of transmission The need to consume only pasteurized milk /dairy products Active TB: may return after therapy has started, symptoms have resolved, and health care provider has deemed case noninfectious. Latent TB: no exclusion necessary. Warts (Human Papillomavirus, HPV) Appearance varies depending on locations: Feet: sore, pebbly surface, circular with speckled core; Knees/forehead: smooth, flat, flesh colored; Genitals: moist, cauliflower like, fast growing 3 months to several years Direct contact with lesions or contaminated surfaces such as gym, pool, and locker room floors and benches Unknown, but probably as long as visible warts are present. Avoid direct contact with warts and contaminated surfaces Treatment of infected person Use of disinfectant on floors and benches on a routine basis Age appropriate vaccination to prevent genital warts No exclusion necessary Page 18

19 How Diseases Are Spread: Knowing how diseases are spread can help you prevent illness. There are five modes of transmission (ways that diseases are spread from one person to another), airborne, droplet, direct contact, fecal oral, and blood borne. Each disease follows one of these following ways of transmission. Airborne: Fine moist particles are coughed or exhaled into the air by a contagious person and inhaled into the body of a susceptible person. Droplet (mucus and secretion): The droplets from nose, mouth and throat are spread by sneezing and coughing; these germ filled secretions fall on all surfaces. When someone touches these surfaces they contaminate their hand and infect themselves by touching their own eye, nose or mouth. Direct Contact: Germs are spread when an infected person touches someone or something and then a susceptible person in turn touches the same area. This includes objects like hats, combs, and bedlinens. Fecal Oral: Very small particles of germs from feces contaminate hands of sick individuals after bowel movements. Items touched by these people become contaminated (toilet handles, water faucets, door knobs, food). Someone touching these same items or eating food prepared by infected people can themselves become infected and pass on the disease. Blood Borne/ Body Fluids: Germs carried in the blood and other body fluids get into the body of another person. Some methods of transmission are needle sharing, unsafe sexual contact, splashed blood or body fluids into cuts or mucous membranes (eyes, mouth). References: 1) Control of Communicable Diseases Manual. 19 th Edition. David L. Heymann, MD Editor. American Public Health Association. 2) Red Book 2012: Report of the Committee on Infectious Diseases. 29 th Edition. American Academy of Pediatrics. 3) Epidemiology and Prevention of Vaccine Preventable Diseases. 12 th Edition, Centers for Disease Control and Prevention, May ) Managing Infectious Diseases in Child Care and Schools. 2 nd Edition, American Academy of Pediatrics, ) Revised 02/27/2013 Page 19